MEDICARE: MS. SUSAN CARRIE MANCUSO FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	F330754-1	NY

General Provider Information

NPI Number	:	1063413375
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SUSAN CARRIE MANCUSO FNP

Provider Business Mailing Address
First Line	:	720 LAFAYETTE AVE
Second Line	:
City	:	BUFFALO
State	:	NY
Zip	:	14222-1448
Country	:	US
Telephone Number	:	716-885-6507
Fax Number	:

Provider Business Practice Location Address
First Line	:	3435 MAIN ST
Second Line	:	UNIVERSITY OF BUFFALO /MICHAEL HALL
City	:	BUFFALO
State	:	NY
Zip	:	14214-3001
Country	:	US
Telephone Number	:	716-829-3316
Fax Number	:	716-829-2564

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/09/2005
Last Update Date	:	07/08/2007

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